PHARMACOKINETICS

“What the body does to the drug”

Part 1B Course 2012

College of Anaesthesiologists of Sri Lanka
Nalini Rodrigo
 PRE-LECTURE MCQ

1. Lipid soluble drugs :

A. can cross cell membranes
B. are well absorbed from the gut
C. are metabolized in the liver
D. are directly excreted by the kidney
E. have a large volume of distribution

A, B, C, E.
2. Water soluble drugs :
A. have a small volume of distribution
B. are well absorbed from the stomach
C. undergo rapid renal excretion
D. undergo rapid hepatic clearance
E. crosses the blood brain barrier

A, C.
What does the body do to drugs ?
• Absorption (lipid solubility)
• Distribution
Protein binding
Lipid solubility
Ionization (pKa & pH)
• Elimination - Clearance
Hepatic metabolism (lipid solubility)
Renal excretion (water solubility)
 Break the Book-Brain Barrier !
Know the simple rules (& any exceptions)

1. Lipid sol drugs cross all cell membranes (BBB, Vd, Cl)
2. Basically, most drugs are basic (6 weak acids Pento,Pro, Para,
Pen,Pheny, asPirin

3. Weak bases inonize in acid pH (&vice versa)

At pH 2units <pKa (100 times as acidic) both acids & bases are
99% protonated AH or BH+. (At 2>pKa non-protonated A- or B)
4. Only un-ionized can cross cell membranes (trapped if they ionize)
5. Most drugs are given in small doses & obey 1st order
kinetics (exponential elimination, high hepatic Cl)
6. T½ α =3min, T½ β = 3h, Vd = 3L/Kg, Cl =3ml/Kg/min
(Exceptions : SLOW Pento, BZ, ketamine , & RAPID Propofol, Alf, Remi
 What happens to drugs in the body ?
Effect site
(Lipid sol)

Trapping
Bio-availability Vd (Ionization/Pr
Fraction reaching (lipid sol)binding)
systemic circulation
i.v. =1, other route<1

(lipid sol)
(water sol)
 LIPID / WATER SOLUBILITY
• LIPID SOL. • WATER SOL.
• Cross all cell membranes • Highly ionized
(BBB, gut, liver, tubule, placenta) • Cannot enter cells
• Well absorbed (gut,sl) • Poor absorption
• Vd large >> ECF + ICF 1000L • Vd = ECF = 3+12 L
• Hepatic 1st pass metabolism • Little metabolism
• Renal tubular re-absorption • Excreted in urine
• Eg. All CNS drugs • Eg. relaxants
 LIPID SOLUBILITY
• Lipid sol = Oil / water coefficient at pH 7.4
• Morhine 1.4
• Alfentanil 13
• Fentanil 860
• Thiopentone 600
• Propofol 6000
• Diazepam high
• Midazolam very high
 Andes
South American Incas

• Chew coca leaves with lime for

CNS stimulation

Uptake of lipophyllic base in alkaline saliva

Enhanced by lime (more alkalinized)
SL : Bio-availability high
If swallowed : Hepatic metabolism reduces bio-av
 SOUTH AMERICAN INDIANS

• Arrow poison curare

• Animal poisoned & paralyzed
• Muscle eaten

Water soluble – not absorbed

Bio-availability v.v. low
 What factors affect ABSORPTION ?
• Permeability : size
lipid solubility
ionization
• Surface area : lungs, GIT
(acids absorbed greater in SI 100sq.m.)
metabolism by G.I. flora (digoxin)
• Concentration gradient : dose
blood flow
ion trapping
FACTORS AFFECTING
ABSORPTION
• SIMPLE DIFFUSION
1. Molecular size
2. Protein binding
3. Lipid solubility (optimum partition coefficient)
Cell membrane pores 0.4nm (most drugs larger)
• ACQUEOUS ABSORPTION
1. Molecular size
2. Osmotic gradients
Capillary endothelial cell open channels 4.0nm BBB glial astrocyte
tight junctions
• ACTIVE CARRIER TRANSPORT (saturable)
Glucose, aminoacids, peptides
What factors affect DISTRIBUTION ?

1. Lipid solubility / Ionization

2. Molecular size
3. Plasma protein binding / conc.
4. Tissue protein binding
5. Body size & composition
Degree of binding on either side of barrier
 PROTEIN BINDING

What is protein binding ?

• Free drug + free protein Drug-Protein complex

• Reversible in milli secs (weak bond : ionic, H2, VW)
• If free drug is rapidly extracted, dissociates in one pass
• Most lipid sol drugs bind to plasma proteins
What are the binding proteins ?
1. ALBUMIN
Selective sites for acidic drugs (salicylates, barbs)
Binding site 1 for warfarin & ph.butazone
Binding site 11 for diazepam & ibuprofen
Also for fatty acids & bilirubin
2. GLOBULIN Alpha 1 Acid Glycoprotein for basic drugs
(LA, propranolol, chlorpromaz, disopyramide, morphine)
3. LIPOPROTEINS
Dissolution of lipid soluble drugs (not true binding)
SELECTIVE BINDING SITES
Are PPB interactions important ?

• Cp, Vd, Cl, GFR,

all inverseley proportional to PPB
• Usual Cp measurement is total Cp
Useful measure is the active free Cp
(complex & costly)
*Are PPB interactions important ?

• Important only if > 95% PPB

warfarin, phenytoin, proranolol, diazepam
Eg. 98% bound = 2% free for effect
96% bound = 4% free, doubles effect
70% bound, 30% free for effect
68% bound, 32% free for effect (minimal change)

Propofol 98% bound. Thus large central comp = 16L

Heparin large molecule Pr bound Vd = Blood volume
*Are PPB interactions important ?

• ANSWER : No, not really (except for exam!)

“because” Increase of free Cp also
increases both distribution & clearance
So its soon redistributed & metabolised
The original steady state is resumed
(unless metabolism is also affected)
 * TISSUE PROTEIN BINDING more
important because of DRUG TRAPPING
PLASMA TISSUES
90% bound 99.8% bound
FREE (10) FREE (10)

BOUND (90)
BOUND (4990)

Most drugs are basic & so bind tissue proteins. Vd >1-2L/Kg

 * Bio-availability
How fast : onset time
How much : extent
Peak conc.

F absolute = 100 x AUCpo x D iv

AUC iv x D po
(dose corrected)

Absolute Bio-av compares to i.v.

Relative bio-av compares 2 drugs
* = Bio-equivalence

1. Blood samples of plasma conc vs time

2. If primary renal excretion, can measure total amount in urine after one dose
in 7-10 T ½β to ensure full complete excretion
* Bio-availability AUC s
 PHARMACOKINETICS :
MATHEMATICAL MODELS
OF
DRUG DISTRIBUTION
OVER TIME
 ONE COMPARTMENT MODEL

Vd 14L = ECF Relaxzants, Remifentanil

Plasma conc. reflects VRG

1 COMPARTMENT MODEL
(Relaxants, Remifentanil)
Cp if drug rapidly distributes in plasma & VRG
(constant relationship – not identical conc.)

Vd = Theoretical volume needed

to contain the amount of drug
(homogenously distributed)
at the conc found in plasma

Check Cp immediately
 Vd = “Apparent” Vd
LOW Vd
1. Blood vol : Plasma protein bound = 5L
Aspirin, Warfarin, Heparin
2. ECF : Relaxants (charged), gentamycin = 14L
HIGH Vd
1. ECF + ICF : Lipid soluble drugs >> 42L
2. >>TBW : Tissue Pr bound - basic drugs
Digoxin 7L/Kg, propofol 5L/Kg, morphine 4L/Kg = >300L
Ciprofloxacin 2L/Kg, Azithromycin 31L/Kg,
Chloroquin 200 L/kg = 13,000 L
TWO COMPARTMENT MODEL
 THREE COMPARTMENT MODEL
(most drugs ) Propofol ½ lives given

VRG

Fat & poorly perfused tissues

250 L
What happens to the Cp with time ?
Time dependency described by TC or ½ life

Vd
Cp reduces exponentially
A constant proportion eliminated/h Kel
(varies with different drugs & patients)

Cl
50%

* T½ =0.693xTC TC h

T1/2
TC min
 T ½ : Characteristics of exponential function
T ½ = time to reach 50 % = 1h
TC = time to reach 63.2% = 1.44h

Rate of elimination
changes
T½ =0.693xTC 32mg/h,

Elimin rate constant 16mg/h,

Kel = 0.693
T½ 8mg/h

4mg/h

TC
 EXPONENTIAL
FUNCTION !

1st half =2³²-1

= 100,000Kg {
4G

>1 half
st 2nd half of chessboard

“exponent” is 64 = how many times

the base 2 is multiplied by itself
“natural” base is e = 2.718… Rice >Mt.Everest
natural log = 0.693 264 -1
 *Give examples of exponential functions

• Radioactive decay
• Bacterial / viral growth (1doubles/h=>16,000000/day
• Population growth
• Vehicle depreciation
• Compound interest
• Water leaking
 * Half-life and Kel (inverse relationship)
4
Kel = 0.693
T 1/2
Conc (mg/L)

Low Kel / Long t ½ K = 0.693 = 0.1

2 5.4
t½= Inefficiently eliminated 10%
5.4 h
t½=
1 2.3 h High Kel / Short t½K = 0.693 = 0.3
2.3
Efficiently eliminated 30%
0
0 2 4 6 8 10
Time (h)
 (30%)
Elimination Rate Constant Kel =0.3 h-1
D =400 mg, Cp 4mg/L. V =100 L
Mass = 4 mg/L x 100 L = 400 mg Kel = rate of elim
4 Rate of elim = 400 mg x 0.3 h-1 dose in body
= 120 mg/h
Conc (mg/L)

3 Mass = 2 mg/L x 100 L = 200 mg

Rate of elim = 200 mg x 0.3 h-1
= 60 mg/h

2
Mass = 1 mg/L x 100 L = 100 mg
Rate of elim = 100 mg x 0.3 h-1
= 30 mg/h
1
Exponential curve
Constant proportion eliminated/h
0
0 2 4 6 8 10
Time (h)
 IONIZATION
• pKa =pH at which 50% of drug is ionized
• Ionized part cannot cross cell membranes
• Acidic drugs ionize more & accumulate in high
pH areas eg. aspirin absorption
• Basic drugs ionize more & accumulate in low
pH areas eg. intracellular
*eg. OPIOIDS given i.v. accumulates in stomach
*eg. LA accumulates in foetus in distress
How can you tell whether a drug is
more ionized or un-ionized ?

• Is the drug acidic or basic ?

• What is the pKa of the drug ?
• What is the pH of the environment ?
• Is the pH of the environment more
acidic or alkaline than the pKa of the
drug ?
 14L ecf
Propofol Relaxants

Thiopentone Pethidine

WEAK Morphine
ACIDS Codeine 200L (tbw x5)
Alfentanil

Midazolam WEAK
Acetyl salicylic
BASES % ionized at 7.4
10L Alf Mor Su Fent Peth
Diazepam pK : 6 7.7 8 8.5 9
Ionized : 12 77 80 85 90%
ION TRAPPING DUE TO IONIZATION
after crossing

• When pH=pKa, Ionized =Unionized

Ionized = 1 = 100
Un-ionized
Ionized = 10 (pH-pKa)
Un-ionized
IONIZATION causing absorption of a
weakly acidic drug pKa 2.4
STOMACH pH 1.4 PLASMA pH 7.4
Ionized = (pH-pKa)= - Ionized = (pH-pKa)=
1 5
IONIZATION causing excretion of a weakly
acidic drug pKa 3

URINE PLASMA pH 7 URINE pH 8

pH 5 Ionized = (pH-pKa)=4
Ionized = (pH-pKa)=5
(pH-pKa)=2

Ion 100
Union 1
 pKa & Ionization simplified

BASE at pKa 50% ionized

• Add 2 pH points (more alkaline) = 1% ionized
• Reduce 2 pH points (more acid) = 99% ionized

ACID vice versa

 ENHANCING EXCRETION OF
POISONS
*ALKALINE DIURESIS ACID DIURESIS
+ ascorbic acid, NH4Cl
• Salicylates • Amphetamines
• Phenobarb • Quinine
• Tri cyclics • Phencyclidine
• Nitrofurantoin
• Pethidine
Why is LA more toxic in acidosis ?
• Base ionizes more – Vd less, hepatic Cl less
• PPB & tissue protein binding less
INCREASES FREE DRUG
• Acidosis & PaCO2 increases blood flow,
absorption, cerebral conc.
• Intracellular trapping (brain, heart, fetus)
• Reduced cerebral threshold for convulsions
INCREASES TOXICITY
CLEARANCE : VOLUME
of plasma cleared of drug

Volume of blood (or plasma)

cleared of drug/unit time
(irreversible elimination -
not redistribution)
Clearance by all routes
(hepatic, renal, other)
important for long term dosing
to get correct SS
Depends on Blood flow
Intrinsic Cl
Protein binding
 Clearance, Vd & Kel

Vd = 20 L
Cl = 4L / h = 20% / h
= 20% of drug eliminated / h
Vd
= 20L Kel = 0.2h-1.
Kel = Clearance / Vd
Kel = Cl / Vd or Cl = Kel x Vd

Clearance
= 4L/h
 HEPATIC BIO-TRANSFORMATION
PHASE 1
• Oxidation : most (barb, opioid, steroid, MAO)
• Reduction : few drugs (chloral )
• Hydrolysis : esters (sux, atrac, esmolol, LA)
PHASE 11
• Methylation : COMT, histamine
• Acetylation : AcCoA, PABA, sulphas
• Glucuronidation : bile salts, paracetamol, steroids, morphine
• Glycine : Nicotinic acid
FIRST PASS : Propranolol, morphine i.v. 1mg, oral 30mg
 FIRST PASS PULMONARY UPTAKE

Basophyllic amines pKa > 8

Lignocaine, proranolol,
Pethidine, fentanyl, alfentanil, sufentanil

Uptake 65% of first dose

• Reduces peak effect
• Reduces side effects (LA)
• Drug reservoir
 RENAL CLEARANCE

• Water soluble drugs and metabolites

parallels creatinine clearance
Gentamycin Kel 0.3/h
reduced to 0.1/h in renal failure
• Lipid soluble drugs
T1/2 is 100 years if not metabolized!
eg. Thiopentone completely reabsorbed
 ELIMINATION HALF - LIFE
• Time to reduce to 50% of Cp after SS
• Directly proportional to Vd T1/2 = 0.693 x Vd
• Inversely proportional to Cl Cl
• Independent of dose / plasma conc.
• Time to ELIMINATE 50% of drug from the BODY
(from plasma & redistributed back from periphery)
• ½ lives 1,2,3,4,5, drug removed 50,75,88,94,97%
• Not relevant to offset of anaesthetic drugs (eg.TPS)
 ELIMINATION HALF LIFE
• Is dependent on Vd & Cl (not vice versa)
• eg. Liver & kidney may be very efficient clearing drug
from plasma, - but if Vd is large, only a small fraction is
in plasma and redistribution will increase Cp = long t1/2

CLEARANCE
More precise, & model independent (1 or 2 comp)
Useful to calculate multiple dosing, non-i.v. routes, disease
Cl = Vd x Kel = Vd x 0.693
T1/2
 Elimination Rate Constant Kel
• 1st order : A fixed proportion of the drug is
eliminated per unit time eg. 10% = 0.1/h
• K = rate of elimination ÷ dose
Eg. 2mg/h ÷ 40mg = 0.05/h (5%)
Inverse relationship between T1/2 & Kel
Kel = 0.693 T1/2 = 0.693
T1/2 Kel

If T ½ is 5h, K = 0.693/5 = 0.138/h (13%)

 Kel & T ½ inversely proportional
Kel / h T1/2 h
• Digoxin 0.01 • 40
• Diazepam 0.02 • 33
• Theophylline 0.06 • 11
• Propranolol 0.18 • 2
• Acetaminophen 0.28 • 2
• Gentamycin 0.35 • 2
• Lignocaine 0.43 • 1.6
Consider a drug :
Dose 300mg, dosing interval 24h,
Fraction absorbed 0.7 (70%), Vd =40L, T1/2 =15h

1. Calculate Elimination rate constant

Kel = 0.693 / T1/2 (15) =0.0462/h
2. Calculate Concentration at steady state
Css = (F x Dose / dosing interval) / Kel (0.0462) x Vd
= (0.7 x 300/24) / (0.0462 x 40,000)mg/ml = 9 / 1.8µg/ml
= 5µg/ml at 24h = 2.5 µg/ml at 48h
Halve the dosing interval (12h) to double the conc (10)
Halve the dose (150mg) to halve the conc
Cp ZERO ORDER KINETICS
Drugs eliminated at a constant rate
(large doses)

Cp
FIRST ORDER KINETICS
Drugs eliminated exponentially
(small doses)
LOW DOSE Alcohol binge at midnight,
First order elimination fail breath test at 7am!

HIGH DOSE
Zero Order Elimination
(rate independent of substrate conc)

LOW DOSE
First order elimination
(rate dependent on substrate conc)
 * Michaelis Menton Kinetics
Enzyme catalyzed reactions
• M&M explained the effect of substrate conc on enzyme activity
• Rate (velocity) of reaction depends on quantities of enzyme,
substrate and intrinsic property of enzyme (Km)
• Rate reduces as substrate conc increases (unlike normal
chemical reactions) = rectangular hyperbola
• This is due to enzyme saturation due to formation of an E-S
complex (reversible).
• Implicates that E <<< S
 Michaelis-Menton Kinetics
Effect of substrate conc on enzyme activity

Mixed order
Zero order. [S]>>Km
[ES]=[E]total

Km = Michaelis constant
= affinity of enzyme for substrate
= stability of enzyme-subs complex

1st order.
[S]<<Km
 Extraction ratio & Clearance
E = Cin - Cout
Liver
Cin Cout Cin
E = 10 – 4 = 0.6 (60%)
10 mg/L 4 mg/L
10

10mg/L 0mg/L E = 1 Complete clearance

Assume liver blood flow 2L/min, Clearance =2L/min

If E=0.5, Q 2L/min, Clearance 1L/min

Clearance = volume of blood effectively cleared

of drug in unit time = Q x E

Extraction ratio is a measure of the EFFICACY of removal, not extent of metabolism

Eg. Phenytoin, diazepam, valproic completely metabolised by liver, but have a low ratio
 HEPATIC CLEARANCE
Hepatic blood flow x Extraction ratio
High ratio >0.6
Clorpromazine 100
Imipramine 100
Lignocaine 100
Amitryptiline 100
Ca channel blockers
Propranolol
High efficacy Morphine, Pethidine

Low ratio
Phenytoin 1g
Tolbutamide 1g
Chlorpropamide 250
Low efficacy Theophylline 200mg

Pr bound restrictive Cl
Diazepam 10mg
Warfarin 0.5mg
 HIGH EXTRACTION LOW EXTRACTION
Drugs Most drugs Few drugs
Dose LOW dose HIGH dose
Examples Opiates, propranol, LA Aspirin, phenytoin, alcohol

Extraction High ratio > 0.7 Low ratio < 0.5

Constant proportion Constant amount
Kinetics 1st order (exponential) Zero order (straight line)

Clearance >free drug (PPB cleared) < free fraction

Enzymes > drug Drug > enzymes
Limited by Perfusion only Enzyme capacity
Enzyme No change Cl increased
induction
 Kinetics of increasing dosage
• Low dose : first order increase in Cp
• Enzyme saturation occurs
• Thereafter : zero order
• Rapid rise in Cp with small increments
• Zero order kinetics within normal Zero order

therapeutic range eg. Pento infusion1 order

st

Phenytoin (do blood levels)

• Rate of elimination increases as Cp falls
Do all lipid soluble drugs have similar
pharmacokinetics ?
MOST Greater Lesser

T ½ alpha
(minutes)
3 Ketamine
Diazepam
Remifent
Alfent
T ½ beta
(hours)
3 TPS
Diazepam
Remi
Propofol
Vd L/kg
3 Diazepam Remi
Alfent
Cl ml/kg/min
3 Diazepam Remi
LIPID Most drugs Greater Lesser Remi
SOLBL

T½ 3 Min Ketamine 15 Alfent 1 Remi 1

Alpha Midaz/diaz 30

T½ 3 Hour Thiopento 12 Propo 1 Remi

beta Diazepam 30 Alfent 1 3 min!
Midaz 2
Vd 3 L/kg Propofol 5 Alfent 1 0.3
Cl 3ml/kg/min Propofol 30 Diazepam 0.5 40-60
(hepatic blood Mor/peth 20
flow 13 m/k/m) Al/F/Sufent 5/10
Midazolam 10
 Half-life (T½β) & Half-time (CST½)
• Elimination T½β is a constant for a drug
• Accurately represents drug action offset only in
1comp models or after SS has been reached
• GA drugs are multi-comp models
• Pento BOLUS wake up time much faster than
predicted by T½β (half-life) due to redistribution
to peripheral compartment. (T1/2 α relevant).
• Pento infusion: wake up time depends on
duration – half time changes - “context sensitive”
• Remifentanil is context insensitive T½β = CS T½
 Context Sensitive T½
• Time related to duration of infusion
• Time taken from point of cessation of infusion.
• CS T½ = T½β only after Steady State is reached
• CS T½ < T½β before SS is reached
• CS T1/2 prolonged due to cummulation (if dosing
interval <4 half lives, Vd is large & Cl is
low)
 * What is Steady State ?
• State of equilibrium after repeated doses for
long duration to allow build up of plasma conc
& keep it constant.
• Time needed is 5 x T½ (or 3xTC)
• Rate of administration = rate of elimination
• If dose & frequency remains constant, plasma
conc remains constant
Why do you prefer midazolam to diazepam ?
• T ½ alpha 30 min for both (recovery by redistribution - high Vd)
• T ½ beta M=2.5h, D 72h +metabolites
• Small dose : no difference
• Large dose or infusion : Midazolam very much faster offset

Cs ½
Mins.
Diazepam (slow Cl 0.5 ml/kg/min)

Midazolam (rapid Cl 10 ml/kg/min)

SS =Tβ=2h
120

Remifentanil (Vd 0.5, Cl 40, Tβ 3min)

1 2 3 4 5 6 7 8 9 10 hours
 Why does propofol have a short Cs ½ time ?
1. V. lipophyllic : redistribution to large Vd lowers Cp
2. High Cl : >> hepatic blood flow (extra hepatic met) counteracts
the return from large Vd when infusion stops
• Slow return from large dose of drug in deep peripheral slow
equilibrium compartment (fat) has no effect site relevance

Cs ½
Mins. Long T½β (5-12h) drug with short CST½ 20-60min

60
40 Propofol SS not reached, large Vd, high Cl 40
20
Remifentanil (Vd 0.5, Cl 40)
1 2 3 4 5 6 7 8 9 10 hours
 What is the best opiate for
RAPID onset / offset after a BOLUS injection ?
% of peak conc.
BOLUS

100
Sufentanil
75
Fentanyl
-
50

25 Alfentanil

0 Remifentanil
0 2 4 6 8 10
Minutes since bolus
What is the best opiate for infusions ?
300min

4h
CsT ½
(mins) Fentanyl INFUSION
(1h)
120 Longest slow eq comp
100 Small Vd Sufentanil (CsT½<T½β
80 even after 8h)
60 SS =Tβ=1h
50 Alfentanil (> 8h)
40 45
20 20 30min
3 3min
Remifent (any duration)
1 2 3 4 5 6 7 8 Context insensitive
Infusion duration (hours)
 Why prefer alfentanil to fentanyl ?
Alfentanil
• Less lipid soluble
= smaller Vd, less cummulation, Cp rapidly altered
• Lower pKa 6.5 (fentanyl 8)
= 90% non-ionized = onset 1min
• Cl less, but small Vd = short t ½
• Potency ¼ but immaterial (small Vd)
• Pr binding higher but immaterial
(a) Continuous (b) Intermittent bolus (c) With initial loading dose

B = Bolus (loading at high rate)

E = Elimination (Cl - slower rate)
T = Transfer to periphery (v.slow)

Loading dose = Desired conc. SS x Vd

Maintenance dose = Desired conc. SS x Clearance
*Explain Michelis Menton Kinetics
 Enzyme catalyzed reactions (MM)
• Velocity of reaction depends on quantities of enzyme,
substrate and intrinsic property of enzyme (Km)
• They reach a maximum, rate of reaction reducing as
substrate conc is progressively increased
(unlike normal chemical reactions)
• Rate (velocity) of a reaction plotted against substrate
conc gives a rectangular hyperbola
• This is due to enzyme saturation due to formation of
an E-S complex (reversible).
• Implicates that E <<< S
Substrate conc at ½ max velocity
= Km in mMoles/L
 MICHAELIS MENTON KINETICS
• M&M explained the effect of substrate conc on
enzyme activity
• Km = Michaelis constant
= affinity of enzyme for substrate
= stability of enzyme-subs complex
This determines its turnover number
• Kcat = Enzyme turnover number
= max no. of moles of substrate that enzyme
can convert to product/catalytic site/unit time
 MM kinetic equations
• Enzyme catalyzed reactions which obey MM kinetics
• Rate of met V = Vmax [S] M-M equation describes a
rectangular hyperbolic curve.
Km + [S]
1st order when conc [S] is <<Km. V= Vmax[S]
Km
Zero order when [S] is >> Km. V= Vmax[S] = Vmax
Vmax
[S]
Vmax Zero order
2
1st order
0
[S]
1st order. [S]<<Km
Mixed order
Zero order. [S]>>Km
[ES]=[E]total
 Why call them 1st order & zero order ?
Rate constants & Reaction order
k1
• E + S ------ ES --k2--- E + P (k2 = Kcat)
k-1

• Rate constant (k) measures how rapidly a reaction occurs

A k-1 k1  B + C
Rate (v, velocity) = (rate constant) (concentration of reactants)

• 1st order rn (rate dependent on conc of 1 reactant) v= k1 [A]

• 2nd order rn (rate dependent on conc of 2 reactants) v= k-1[B][C]
• Zero order rn (rate independent of reactant concentration)
Orders of reactions 0, 1st, 2nd, nth
• How each reactant affects the rate of the reaction
(experimentally determined)
• If a reactant has no effect on the rate [A]˚ = zero order
• Rate directly proportional to reactant conc [A] ' = 1st order
• Rate is proportional to square of conc [A] ² = 2nd order
• Rate depends on two reactants [A] ' +[B] ' = 1+1 = 2nd order
• [A]˚ + [B] ' = 1st order [A] ' + [B] ² = 1+2 = 3rd order
• Add the powers

• Time to halve the concentration in a 1st order reaction is fixed

= Half life = 0.693 / K (rate constant )
 To determine the reaction order,
list X, log10X, and 1/X in a table, then plot each against time.
The one with the linear plot is the order of the reaction.

rate conc-time
Order half-life linear plot
expression relationship

0 rate = k X0 - X = k X0/2k X vs t
X

log X0/X =
1st rate = kX kt/2.30
0.693/k log X vs t Log x

2nd rate = kX2 1/x -1/X0 = kt 1/X0k 1/X vs t 1/x

time
 Michaelis-Menton Kinetics

• Sucrose + H20  Glucose + Fructose

• Held [S] constant & varied the amount of
enzyme added
E + S <-> ES <-> E + P v

[E]
• Held [E] constant & varied the amount of
substrate added
Zero order with
respect to S
Vmax = Km v

2 1st order with

Km [S] [S] respect to S
 Initial velocity Assumption
• Measurements made to measure initial velocity (Vo).
• At Vo very little product formed.
• Therefore, the rate at which E + P react to form ES is
negligible, and k-2 is 0.
• Therefore instead of E + S <-- k1/k-1 --> ES <----Kcat/k-2----> E + P

• We assume E + S <---k1/k-1---> ES <---Kcat---> E + P

• Also since [S] >>>[E], [S] is assumed to be constant.
 SS Assumption
• E + S <----k1/k-1---->ES<-----Kcat-----> E + P
• Steady state Assumption = [ES] is constant.
• The rate of ES formation equals the rate of
ES breakdown
• Rate of ES formation = k1[E][S]
• Rate of ES break down = k-1[ES] + kcat[ES]
= [ES](k-1+ kcat)
Therefore……….
1) k-1[E][S] = [ES](k-1+ kcat)
2) (k-1+ kcat) / k1 = [E][S] / [ES]
3) (k-1+ kcat) / k1 = Km (Michaelis constant)
 What does Km mean ?
1. Km = [S] at ½ Vmax
Km = [S] that produces ½ maximum enzyme activity
2. Km is a combination of rate constants
describing the formation &
breakdown of the ES complex Vmax 2
3. Km is usually a little higher
than the physiological [S]

0 Km
[S]
 What does Km mean ?

4. Km represents the amount of substrate required to bind

½ of the available enzyme
(binding constant of the enzyme for substrate)
5. Km can be used to evaluate the specificity of an enzyme
for a substrate (if it obeys M-M)
6. Small Km means tight binding
High Km means weak binding
Glucose Km = 8 X 10-6
Allose Km = 8 X 10-3
Mannose Km = 5 X 10-6
MM : Maintaining Blood Sugar for the brain

Normal BS
Hexokinase (brain) regulatory enzyme near Vmax
(product feedback inhibition) Brain gets its glucose.
If BS rises or falls still near enough to Vmax
V

Glucokinase (liver) non-regulatory

If BS rises, gluco-ki rate rises to metabolize it
Vmax If BS falls, gluco-ki gets inactive so brain
2 gets its glucose supply

[S]
Km 5x10-5 2x10-2
 What does Kcat mean ?
1. Kcat is the 1st order rate constant describing
ES E+P
2. Also known as the turnover number because it
describes the number of reactions a molecule of
enzyme can catalyze per second under optimal
condition.
3. Most enzyme have Kcat values between 102 and 103 s-1
4. For simple reactions, k2 = kcat
for multistep reactions, Kcat = rate limiting step
E + S k1 ES E+P
K2/Kcat
k-1
 What does Kcat/Km mean ?
• It measures how the enzyme performs when S is low
• Kcat/Km describes an enzyme’s preference for different
substrates = specificity constant
• The upper limit for Kcat/Km is the diffusion limit –
the rate at which E and S diffuse together (108 to 109 m-1 s-1)
• Catalytic perfection when Kcat/Km = diffusion rate
• More physiological than Kcat
 Limitations of M-M
1. Some enzyme catalyzed reactions show more
complex behavior
• E +S <-> ES <-> EZ <-> EP <-> E + P
• With M-M can look only at the rate limiting step
2. Often more than one substrate
• E+S1 <-> ES1+S2 <-> ES1S2 <-> EP1P2 <-> EP2+P1 <->
E+P2
• Must optimize one substrate then calculate
kinetic parameters for the other
3. Assumes k-2 = 0
4. Assume steady state conditions
 What does Kcat mean ?
1. Kcat is the 1st order rate constant describing
ES E+P
2. Also known as the turnover number because it
describes the number of reactions a molecule of
enzyme can catalyze per second under optimal
conditions.
3. Most enzyme have Kcat values between 102 and 103 s-1
4. For simple reactions, k2 = kcat
for multistep reactions, Kcat = rate limiting step
E + S k1 ES K2/Kcat E + P
k-1
 What does Kcat/Km mean ?
• More physiological than Kcat
• It measures how the enzyme performs when S is low
• Kcat/Km describes an enzyme’s preference for different
substrates = specificity constant
• The upper limit for Kcat/Km is the diffusion limit –
the rate at which E and S diffuse together (108 to 109 m-1 s-1)
• Catalytic perfection when Kcat/Km = diffusion rate
 Limitations of M-M
1. Some enzyme catalyzed reactions show more
complex behavior
• E +S <-> ES <-> EZ <-> EP <-> E + P
• With M-M can look only at the rate limiting step
2. Often more than one substrate
• E+S1 <-> ES1+S2 <-> ES1S2 <-> EP1P2 <-> EP2+P1 <->
E+P2
• Must optimize one substrate then calculate
kinetic parameters for the other
3. Assumes k-2 = 0
4. Assume steady state conditions
 VIVA QUESTIONS
• Why are the ampoule contents of thiopentone
& propofol different ?
• Which would you choose for continuous
infusion – thipoentone or propofol - & why?
• Why are the pharmacokinetics of morphine &
fentanyl so different when their clearance is
the same?
• Why does alfentanil have a more rapid onset
& offset than fentanil ?
 ESSAY QUESTIONS
1. Outline the influences of pregnancy on pharmacokinetics.
2. Describe factors affecting the uptake of orally given drugs.
3. Outline factors determining recovery after ceasing drug infusion.
4. Define the term 'context-sensitive half time'. How does this differ
from the elimination half life? Illustrate comparing thiopentone vs.
propofol, and fentanyl vs. remifentanil.
5. Discuss roles of the plasma esterases on drugs used in anaesthesia.
6. Describe the factors determining transdermal uptake of drugs.
Outline the advantages and disadvantages. Give examples.
7. Describe the clearance of drugs by the kidney.
8. Give a account of drug protein binding and outline its significance.
 9. Define Phase I and Phase II reactions in drug metabolism.
Give examples.
10. Define a 'steady state' in pharmacology. List its advantages and
disadvantages. Outline characteristics which make drugs suitable
for steady state pharmacology
11. Define bio-availability. Discuss factors which determine the bio-
availability of a drug.
12. Discuss how consequences of liver disease may influence drug
disposition.
13. Write short notes on :
1) Measurement of whole body drug clearance
2) Zero order kinetics. 3) Hepatic extraction ratios.
4) Clearance of a drug.
5) Estimation of apparent volume of distribution of a drug
14. Using propofol as an example, explain the
importance of clearance of a drug.
15. Explain how a knowledge of pharmacokinetics of
propofol enables it to be used for induction and
maintenance of anaesthesia by continuous infusion.
16. Explain how differences in kinetics of alfentanil and
fentanyl can influence the way they are administered
i.v.
1. Propofol has a shorter half life than
thiopentone because :
A. the volume of distribution is less
B. hepatic clearance is greater
C. extra-hepatic clearance is greater
D. the dose used is less
E. Renal excretion is greater

B, C,
 2. Alfentanil has a shorter half life
than fentanyl because it :
A. is more lipid soluble
B. is less protein bound
C. has a greater volume of distribution
D. has a greater hepatic clearance
E. has a higher pKa
3. Context sensitive half time is :
A. dependent on the duration of drug delivery
B. dependent on the volume of distribution
C. dependent on hepatic clearance
D. greatest for remifentanil
E. greater for alfentanil than fentanil

A, B, C.
4. Regarding first order elimination kinetics of drugs :

A. a constant fraction is eliminated per unit time

B. drug concentrations are too low to saturate
metabolizing enzyme systems
C. the rate of elimination is governed by the Law of
Mass Action
D. elimination is proportional to hepatic blood flow
E. the half life of the drug is not a constant figure
but is proportional to drug concentration

A, B, C, D.
5. The volume of distribution of a drug is
determined by :
A its pKa
B extent of plasma protein binding
C extent of tissue protein binding
D rate of excretion
E total aqueous volume available

A, B, C, E
6. Binding of drugs to plasma proteins:-

A. increases their pharmacological activity

B, D
B. may depend on pH and temperature
7. The following drugs undergo extensive
metabolism:-

A prilocaine

B A,
paracetamol B, D, E
8. Drugs with a high hepatic extraction ratio include:-

A morphine

B buprenorphine
A, B, C.
9. Bio-availability of a drug may be influenced by:

A hepatic extraction

B A, B,
gut wall metabolism E.
10. Pharmacokinetics of drugs are affected by :

A. patient’s age
B. patient’s weight
C. drug interactions
D. hepato-renal disease
E. genetic polymorphism